Journal of Public Health in Africa 2023; volume 14(s2):2540

School sanitation and student health status: a literature review

Anita Dewi Moelyaningrum,1 Soedjajadi Keman,2 Hari Basuki Notobroto,2 Soenarnatalina Melaniani,2
Lilis Sulistyorini,2 Ferry Efendi3
1Doctoral Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya; 2Public Health
Faculty, Universitas Airlangga, Surabaya; 3Department of Community Health Nursing, Faculty of Nursing,
Universitas Airlangga, Surabaya, Indonesia

Materials and Methods. This research was based primarily on

Abstract a literature review. Boolean technic was used to define the key-
Introduction. UNESCO 2019 said that Indonesia’s education words. The database used for the searching within these documents
has ranked 54 to 120 countries. The Sustainable Development were School Sanitation, Health, and Students. Data were found
Goals (SDGs) contain goals 4, target 4a, indicator 4.a.1. Quality from search engines PubMed, Science Direct, Springer, and
education can be achieved with basic drinking water during school Google scholar. The literature review of this search was done by
the publication range 2019-2022. The search data were conducted
hours, basic sanitation facilities, and basic handwashing facilities.
on 8 October 2022, which Acquired 7 articles that meet predefined
School sanitation is covered at targets 3, 4, and 6 of SDGs. The
criteria.
objective of this review is to identify school sanitation, determina-
Results and Discussions. Schools’ sanitation was identified in
tion of disease, and students’ health status-related school sanitation.

ly
water supply, drinking water supply, rest room, sanitary facilities,
toilet/ latrine, hand washing facilities, cleaning policy, clean and

on
functional toilet, Water Sanitation and Hygiene Programs, and the
Correspondence: Anita Dewi Moelyaningrum, Doctoral Program of knowledge of sanitation. The effect of health-related school sanita-
Public Health, Faculty of Public Health, Universitas Airlangga, Kampus tion was gastrointestinal illness, diarrhea, cholera, dehydration,

e
C, Jl. Mulyorejo, Surabaya, Jawa Timur, 60115, Indonesia. cavities in teeth, undernutrition, stunting, soil-transmitted
Tel.: +62.315920948- Fax: +62.315924618.
E-mail: [email protected]
us
helminths, intestinal parasitic infection, toothache, decay missing,
filled permanent teeth status, and health status of students.
Conclusions. School sanitation affected the student health sta-
al
Key words: health status; school sanitation; students. tus, absenteeism at school, and students’ concentration. Sanitation
facilities are suggested to include laws and policies.
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Acknowledgments: the authors would like to thank the Faculty of

Public Health Airlangga University, Faculty of Public Health
er

Universitas Jember, and also Beasiswa Pendidikan Indonesia for sup-

porting the research. Introduction
m

Contributions: all authors contributed to the design of the study, draft- School sanitation is a concern of the global community.
om

ing, review, and editing. ADM, builds the idea, presentation, and analy- Therefore, it is one of the goals in the Sustainable Development
sis of data; SK, HBN, LS, analyzed the data; SM, FE, build the method. Goals (SDGs). The SDGs had seventeen goals that should be
All the authors approved the final version to be published. reached in 2030. The vision for drinking water, sanitation, and
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hygiene in schools is shown in SDGs 3, 4, and 6. Goal number 3

Conflicts of interest: the authors declare no potential conflict of interest. had 38 targets about health that should be reached. Goal number 4
on

is about universal access to basic drinking water, single-sex basic

Funding: the research was supported by the Faculty of Public Health
sanitation, and basic handwashing facilities in schools, and goal
Airlangga University, Faculty of Public Health Universitas Jember, and
number 6 is universal access to safely managed drinking water
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also Beasiswa Pendidikan Indonesia.

services, safely managed sanitation services, and handwashing
Ethical approval and consent to participate: not needed. facilities with soap and water.1
Quality education is a human right. Every child should get it.
Availability of data and material: Data and materials are available by the Quality education mentioned in goal 4 of SDGs will be achieved
authors. when the school meets target 4a, indicators 4.a.1 said that quality
education is achieved when there have good drinking water, sani-
Informed consent: the manuscript does not contain any individual per- tation, and hygiene in school. Schools are places that have the
son’s data in any form. potential to affect the health of students because students spend
more time every day at school than at home. There are many activ-
Received for publication: 2 December 2022.
ities for all day at school, consequently, should fulfill the require-
Accepted for publication: 8 February 2023.
ments of hygiene and sanitation to support the student’s health.
This work is licensed under a Creative Commons Attribution The research about sanitation showed that sanitation decreases the
NonCommercial 4.0 License (CC BY-NC 4.0). risk of disease,2-4 reduces death and disability, and effected the life
span, especially in a child,5 and sanitation can use as a predictor of
©Copyright: the Author(s), 2023 fever and abortus in pregnant women in Indonesia.6
Journal of Public Health in Africa 2023; 14(s2):2540 There is much research shown about sanitation in the house-
doi:10.4081/jphia.2023.2540 hold, but there isn`t identification of how the school sanitation and
health status to the students. It may cause low attention to school

[page 56] [Journal of Public Health in Africa 2023; 14(s2):2540]

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sanitation. The pandemic COVID-19 teaches us how the impor- Sanitation programs are often tried implementation at schools
tance of school sanitation to support the sustainability of school to improve the achievement of sanitation. Some research was an
activity, including sanitation facilities. Poor school sanitation is analysis of school sanitation with intervention. The sanitation pro-
still a problem around the world. There are only three-quarters of gram is called Fit For School (FIT).9 They tried to analyze the
secondary schools (74%) and two-thirds of primary schools (66%) implementation of the FIT program, integrating school health and
globally had basic water services in 2019, and only 57% of schools water, sanitation, and hygiene intervention which had implementa-
had a basic hygiene service, while 25% neither had hand hygiene tion in the 3 countries, i.e. Indonesia, Cambodia, and Lao PDR.
facilities nor water at the school premises.7 The non-randomized clustered controlled trial and follow-up of
The objective of this research is to identify school sanitation, the two years in the public elementary schools involved 1847 children.
determinant of disease of school students related to school sanitation, Another school sanitation program is called School garden.10 The
and the student health status related to school sanitation. It will encour- programs analyzed intervention programs, including the school
age improvements in school sanitation which can further accelerate garden, nutrition dan water, sanitation and hygiene (WASH),
the achievement of SDGs goals number 3, 4, and 6 in 2030. which involved 682 children aged 8-7 years from two schools ran-
domly allocated to one or three interventions.
The school’s sanitation can improve student health. Some
research analyses the association between water, sanitation, and
Materials and Methods hygiene (WASH) services and the health status of basic-level stu-
The research was primarily based on a literature review. dents ranging from sixth to eighth grades. The method we’re using
The first stage is identification, screening, eligibility and is the causal-comparative research design. There were two groups
included (Figure 1). Reference books were published, as well as consisting of 2 schools; each group improved and unimproved
academic articles, books, and websites related to the keywords. WASH facilities at school. The 768 respondents were analyzed in
Data were found from search engines PubMed, Science Direct and univariate, bivariate, and multivariate.11 The other research with an
analysis of 1,869 schools was conducted in Kampala, Uganda,

ly
Springer, and google scholar. Boolean technic was used to define
the keywords. The database used for the searching within these with a cross-sectional design and conducted the cross-sectional

on
documents were School Sanitation, Health, and Students. Data survey, which was analyzed with a Poisson regression model to
were found from search engines PubMed, Science Direct, identify the factor of water, sanitation, hygiene, and health status
Springer, and Google scholar. The literature review of this search of students (see Table 1).12

e
was done by the publication range in 2019-2022. The article
should be in full text (n=1.503), and then the language should be School sanitation
us
international and open access. The search data were conducted on Basic water is substantial in life. People couldn’t have a decent
8 October 2022, and acquired 7 articles that meet predefined crite- life without water. Schools should provide water for students all
al
ria. the time while they are at school. Basic drinking water and water
for sanitation are important things to decrease transmitted diseases.
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The research showed that schools did not provide a hygiene-

enabling environment, no learning materials, policies, and
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Results resources, and also the lack of access to sanitation on hygiene and
Sanitation and hygiene support each other. Hygiene didn’t health.13
m

implement without sanitation facilities. School sanitation facilities The other research showed that said that rinse free handwash-
ing, such as using hand rub, hand sanitizer, gel, and foam reduces
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should be provided by the school to fulfill the right of children and

reach the SDGs goals target number 3,4 and 6 which said that Illness-related absenteeism in school, but it may have identified a
health, quality education, and sanitation. The coverage of health small yet potentially beneficial effect.14 During the pandemic situ-
ation, some schools had a program to use hand rub, hand sanitizer,
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for all in target 3 of SDGs should be implemented at schools. It

means that all the facilities that can support the health student were gel, foam, etc., while traditional hand washing had barriers to use
at preschool and school children. Rinse free hand washing was
on

very important. Education quality can achieve when the students

are healthy and satisfied at school. Education quality is the goal implemented to substitute the lack of water when doing the hand
SGDs target 4. Basic sanitation at schools is important to support washing. Although rinse-free hand washing reduces illness-related
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healthy students. Basic sanitation at schools, such as water supply,

toilet, and hygiene facilities, supports not only the student’s health
but also the satisfaction of students while they learn at school.
The research analysis of the article can explain how sanitation
correlates with the health of the students. Seven articles meet pre-
defined criteria, which analyze the school sanitation condition and
health of students, the determinant of disease of school students
related to school sanitation, and the student health status related to
school sanitation. Some research showed that school sanitation
should be a requirement of the standard of school sanitation. The
articles involved a large population of students and combined
many methods. Randomized Controlled Trials (RCTs) with a pop-
ulation aged between two and 18 years old.8 Their research analy-
sis about comparing rinse-free hand washing (hand sanitizer, gel,
foam, hand rub) with conventional hand washing using soap and
water. The pandemic COVID-19 made some schools use rinse-free
hand washing to control the transmitted disease than using soap
and water. Figure 1. Flow diagram.

[Journal of Public Health in Africa 2023; 14(s2):2540] [page 57]

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absenteeism at school, there is a small beneficial effect over tradi- water in the school restroom affected students’ condition. The rest-
tional hand washing with running water and soap and also it can be room should be clean every time. The policy of cleaning the sani-
harmful to health and the environment.15-17 Hand washing with tation facilities had an important thing in the sustainability of san-
running water and soap is the best way to control the transmitted itation facilities. The policy had the main role of making the sani-
disease, especially at school. The lack of water is the reason why tation facilities clean. The cleaning policy, which supports sanita-
the students didn’t wash their hands after using the toilet.18 tion, was very important. The research showed that undernutrition
School is the place where students spend a lot of time every was associated with the lack of a school restroom cleaning poli-
day. They interact with friends, objects, and the environment at cy.22 The policy is important to the sustainability of the program
school. The frequency of hand washing is important. Some sanitation.23 Poor planning impacts the sanitary service.24 Many
research showed that hand washing with soap could reduce the dis- factors influence the making of water policy, such as interests,
ease,19 and the frequency of handwashing also correlates with a access to information, habits, and customs.25 Sometimes, the exist-
decrease in the disease.20,21 The water for handwashing should be ing policy is not effective in promoting appropriate sanitation.26
required for the quantity and quality of clean water. School sanitation programs help the sanitation implemented well.
The restroom was an important facility at school. The lack of Programs should be supported with policy.

Table 1. The school sanitation, disease, and health status relate to school sanitation.
No Title Author Population School sanitation Consequence Health status
Pubmed

1. Rinse free hand wash for Zachary Munn et al. 30,747 participants Water supply Poor handwashing Students gastrointestinal

ly
reducing absenteeism among Illness
preschool and school children

on
Science Direct
2. Diarrhea, malnutrition, Stephanie 15 public schools, Water supply Poor handwashing Diarrhea
and Dehydration associated O Sangalang et al. primary and

e
with school water sanitation secondary
and Hygiene in metro Manila,
Philippines: Across sectional study
schools students
us Handwashing with soap Diarrhea, Cholera
before eating and defecation
al
Lack of water in the school restroom Dehydration
Cleaning policy Lack of cleaning policy Undernutrition
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at school restroom
er

Number of school restrooms Diarrhea, stunting,

undernutrition
m

Springer

3. WASH and diarrhea-related Ommy 1,781 students,

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sanitation Mushota et al. aged: 14-19 years

and hygiene intervention on
students' knowledge in a
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resource-limited setting
4. Fit for school-based water Denise 1847 children Clean and functional Soil-transmitted
on

sanitation and hygiene program Duijster et al. toilet at school helminths

to improve child health: results
from a longitudinal study in
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Cambodia, Indonesia,
and Lao PDR
Lack of WaSH Decay, missing, and Filled
Permanent Teeth (DMFT)
5. Nutritional and health status Sharesta et al. 682 children Water, sanitation, hygiene Intestinal parasitic infection,
of children 15 months after aged 8-7 years (WASH) program parasitic infection, anemia,
integrated school garden, nutrition, stunting, intestinal
and water interventions: protozoa infection,
a cluster-randomized soil trans, and mitted
control trial in Nepal helminth infection
Google Scholar

6. Effect of School water Sharma et al. 768 students Water sanitation and sanitary Improve hand hygiene practice Health students status
sanitation and hygiene hygiene Facilities
on health status among
basic level students in Nepal
7 Water, Sanitation and Hygiene Ssekamate 1,869 school Safe drinking water and sanitation facilities Oral health (cavity, toothache)
Behaviours and the oral health
status of school-going adolescent
boys and young men in
Kampala Uganda Lack of wash Cavities cause mental health

[page 58] [Journal of Public Health in Africa 2023; 14(s2):2540]

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Using the randomized controlled trial in 12 schools,10 four learning at school. The dehydration condition in students makes
schools were compared with a School garden (SG) program which the immune drop and it increases the risk of disease. Basic drink-
specific education about fruit and vegetable, four schools with SG ing water is a human right for all, including the students, while
programs coupled with nutrition, health, and WASH intervention, they do their activities at school.
four schools control. The data showed that the SG and control Diarrhea, stunting, and undernutrition in the students correlate
increased in parasitic infection, anemia stunting, intestinal proto- with the number of the rest room and toilets at school.22 School
zoa infection, and soil-transmitted helminth infection. The other restrooms had many functions. Children who did not wash their
program Fit for Schools in Cambodia, Indonesia, and Lao PDR, hands with soap and water after using the toilet were likely more
showed that the school-based water, sanitation, and hygiene pro- exposed to fecal, so the risk of infection increased. The diarrhea
gram could reduce the DMFT index and cavity.9,27 infection makes students dehydrate and increases the risk of mal-
There are many factors that influence students when using san- nutrition, weight loss, and stunted growth; consequences of infec-
itation facilities. The research using the Structural Equation Model tion include school absence and increased risk of school dropout.
analysis showed that the cleanliness of the toilet is significant for Student dehydration shouldn’t happen in the students. Dehydration
toilet behavior (path coefficient, 0.81).28 The cleanliness makes it has many effects. It can cause fatigue 176 (44.78%), lack of focus
comfortable when using the toilet. The toilet is the basic sanitation 171 (43.5%), headache/dizziness 160 (40.71%), lightheadedness
that should be existence at school. Some schools didn’t have an 117 (29.7%), muscle weakness 98 (24.94%), rapid breathing 90
adequate number of toilets and lack of knowledge and awareness (22.9%), and muscle cramps 64 (16.28%).35
of water towards poor hygiene behavior.29 The school restroom had affected the health of students. The
The qualitative interview with students aged 16-18 years said prevalence of dehydration among school children is high,36 and
that toilets were dirty, insecure, and unpleasant.30 It makes the stu- severely dehydrated during a school day,37 even extremely high
dents refrain from drinking during school and it will be affected the during school time.38 Water consumption among students is low.39
student’s health. Furthermore, students remained constantly jump- Dehydration impacted students’ cognitive performance.40 At

ly
ing up and down or moving to withhold urine and stool. school, dehydration was associated with the lack of water in a
The school sanitation programs were expected to improve school restroom, and the risk of diarrhea, stunting, and undernutri-

on
school sanitation. Two articles showed that school program sanita- tion decreased as the number of school restrooms.22 Other research
tion reduces disease in school students.9,10 showed that stunting correlates with sanitary facilities and water
The sustainability of school sanitation programs should be treatment.41

e
fully supported by the policy. The revamped toilet made the great- Water was the basic sanitation that should be available all the
est gains in students’ attitudes toward the toilet facilities.31 The
program for operation and maintenance (O&M) in a public school
us
time for students at schools. Without having water to wash their
hands or flush the toilet, students may have been more exposed to
in the Philippines showed that intervention schools had a higher feces. Consequences of fecal exposure include diarrhea, which can
al
percentage of usable toilets and were fully clean than control cause helminth infection. Other research showed that poor sanita-
schools. It means that the program of school sanitation can stimu- tion in school might cause helminth infection.42
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late reaching water, sanitation, and hygiene service.32 The health status of students correlates with school sanitation.
The analysis showed that students from unimprovement facilities
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got sickness higher than improvement facilities at a school.10 Basic

drinking water and sanitation facilities at school showed that more
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Discussion than a quarter of students had a cavity in their teeth and missed
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The student’s disease can cause a lack of school sanitation. school cause of toothache.12
There were seven articles that showed the correlation between stu-
dent disease and school sanitation. There were gastrointestinal ill-
-c

nesses, diarrhea, cholera, dehydration, undernutrition, stunting,

soil-transmitted helminths, parasitic intestinal infection, protozoa Conclusions
on

infection, cavities in students, DMFT index, and health students The school’s sanitation included water supply, safe drinking
status. Diarrhea correlates with poor hand washing at school in the water, cleaning policy, toilet function, sanitation and hygiene pro-
students.22 Students not washing their hands in school was signif- grams, water sanitation and hygiene facilities, which correlate to
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icantly associated with increased odds of diarrhea (OR 1.77, 95% student health such as students’ gastrointestinal illness, diarrhea,
CI = 1.18 to 2.65). The insecure water increases the incidents of dehydration, oral health, undernutrition, stunting, soil-transmitted
diarrhea among children.33 helminths, parasitic intestinal infection, anemia, cavities, DMFT
Poor hand washing among students is due to the difficulties in status.
finding water for washing their hands at schools. The lack of water
at schools makes the students have more diarrhea and increase
absenteeism at school. Diarrhea affects 2.39 billion people global-
ly and caused 1,655,944 deaths in 2016.34 The program of Water, References
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[Journal of Public Health in Africa 2023; 14(s2):2540] [page 61]